Canine impaction- A review

of the prevalence, etiology,

diagnosis and treatment
Y. Hamada, C Timothius, D Shin & V John

M. Anil Kumar
II MDS

Seminars in orthodontics, vol 25, No 2,2019:pp 117-123

Introduction:

 An impacted tooth is defined as a tooth that fails to erupt

after the normal development pattern is complete.
 Maxillary canines are the most common after third molar
teeth.
 Early detection, timely management & appropriate surgical
orthodontic intervention can lead to esthetically &
functionally acceptable outcomes. 2
 Proper positioning & alignment of canine plays an important
role in establishing an acceptable facial contour, esthetic smile
line, and occlusion especially for canine guidance or group
function occlusion.
 Additionally, the presence of an impacted canine may play a
role in root resorption of adjacent teeth.

3
Prevalence and etiology of canine impaction:

 Maxillary canine- 2nd most common

 Prevalence- 0.92% to 2.2%
 Affect females more often than males, at a ratio of 2:1
 Palatally placed : labially placed- 2:1 or 3:1
 Etiology involves multiple broad and complex mechanisms-
namely genetic, systemic and local factors,
 Systemic- endocrine disorders, febrile conditions,
 Local factors:
1. Tooth size-arch length discrepancies
2. Failure of 10 canine root to resorb
3. Prolonged retention or early loss of the primary canine
4. Ankylosis of the permanent canine
5. Cyst or neoplasm
6. Dilaceration of root
7. Variation in timing of lateral incisor root formation 5
 Of all local factors, arch length deficiency is believed to
be the most common cause of labially impacted canines.
 Insufficient arch length limits the amount of space
available for the unerupted canine to erupt normally.
 For palatally impacted canines, the absence of the
maxillary lateral incisor is believed to be the most
common cause for eruption failure .
6
 In order a canine to erupt normally into the arch, the
prevailing theory is that the root of adjacent lateral incisor
serves as a “guide” for the canine to erupt along it.
 When lateral incisor is either missing or malformed, there
is no “guide” for canine to travel along it, as a result canine
will fail to erupt.
 This is known as “guidance theory”.
7
Clinical & radiographic assessments:
 Clinical examination involves comprehensive periodontal
examination.
 Clinical signs of canine impaction include retention of primary
canines and an absence of buccal and palatal bulges when
compared to contralateral side of the affected area after pt reaches
12-15 yrs of age.
 Other include tipping or irregular positioning of adjacent teeth.
8
 Palpation of the alveolar ridge is one way of the most
common clinical methods to identify the location of
impacted canines.
 Ericson showed that approximately 3-5% of impacted
teeth are not clinically palpable based only on clinical
examinations.
 Panoramic, periapical, occlusal, and lateral ceph have
9
been utilized.
 If the tooth is not palpable, 2 or more periapical radiographs
taken at different angles can confirm the position by utilizing
the principle of the SLOB or Clark’s rule- “Same Lingual,
Opposite Buccal”.
 Approximately 90% of the time, clinicians can identify the
position of an impacted tooth on the labial or palatal sides.
 Three dimensional analysis with CBCT has significantly
increased the ability to locate the position accurately.
10
 The customized arch is made on panoramic view, &
customized slice view can be used for accurate detection of
tooth position.

11
 In addition to these, a 3D reconstructed view can be
useful in identifying the exact location of an impacted
canine.

12
 Ericson revealed that the prevalence of root resorption
associated with canine impaction was 12% of lateral
incisors with conventional 2D images.
 When using CBCT imaging, they found that 38% of
lateral incisors & 9% of central incisors have some
degree of root resorption.
 This study revealed that the detection of root resorption
increased almost 50% with CT scanning.
13
 The presence of root resorption might affect the overall
treatment plan whether extraction or retention of those
affected teeth are indicated.
 If extraction is indicated due to severity of root resorption.
 Therefore the use of CBCT scan can definitely contribute to
accurate & timely diagnosis and lead to proper treatment
intervention.
14
Treatment interventions (classification of canine
positions):
 Canine impactions are broadly classified based on their labio-
palatal positions in relation to the alveolar ridge, the axial
inclination and depth of impacted canine.
 Position of impacted tooth is usually classified as per their
relation to the neighbouring teeth and anatomical structures.
15
 The presence of the ectopic maxillary canine based on
the location of impaction and relation to the neighboring
lateral incisor root was classified by Chapokas:

16
 Spontaneous correction of an impacted canine is highly
predictable if the deciduous tooth is removed when the
crown of the permanent ectopic canine was positioned over
the root of the maxillary lateral incisor.
 Surgical uncovering is necessary when the tooth is positioned
beyond the mesial root surface of the lateral incisor.

17
 In the presence of labially impacted maxillary canines,
Kokich recommends the usage of three technique for
surgical eruption: gingivectomy, apically positioned flap
and closed eruption techniques.
 Facially impacted- Open or closed approach.
 Coronally, positioned labially impacted- any of three
techniques
 Apically located- closed eruption technique 18
 Palatally impacted- closed or open approach.
 Most palatal canine impactions can be surgically approached via
gingivectomy procedure, facilitated spontaneous eruptions.
 A fixed attachment appliance is recommended to be connected
immediately after exposure , or spontaneous eruption fails to
occur.
 Tunnel traction is recommended when the primary canine is
present at the time of surgical intervention
19
 Since mandibular impacted teeth are usually located at a
labial or intra-alveolar position, a closed flap approach to
orthodontically erupt the tooth to an ideal position is
recommended.
 In cases of severe impaction or transmigration , mandibular
impacted teeth are more challenging to treat
orthodontically.
 In these situations, it would be prudent to extract the canine
20
Case:
 19-year old patient was referred for surgical exposure &
recovery of impacted mandibular left canine.

21
22
Conclusions:
 Tooth impaction profoundly impacts esthetics & function
for patients.
 There is increasing recognition among dental health care
providers that treatment intervention poses challenges,
owing largely to the complex interrelationships between
normal craniofacial development, functional outcomes, &
esthetic results.
23
Eruption of a Labially Impacted Canine
Using a Closed-Flap Technique and
Orthodontic Wire Traction.- JCO,2012

24
25
26